MEDICARE: JAMIE GORDON RUSSELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	15-0541	NV

General Provider Information

NPI Number	:	1710436506
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMIE GORDON RUSSELL

Provider Business Mailing Address
First Line	:	2005 OAK RIVER ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89134-6706
Country	:	US
Telephone Number	:	702-279-8124
Fax Number	:

Provider Business Practice Location Address
First Line	:	2005 OAK RIVER ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89134-6706
Country	:	US
Telephone Number	:	702-279-8124
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2016
Last Update Date	:	09/22/2016

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